Another Look at Medical Futility
What is medical futility? What does it mean to stop or not start some procedure or treatment because such action is futile? And what does futile mean in this context? Over the past 7 years on this blog, I have started a few threads which included this issue. Once, I presented the definition of futility as described by physician-ethicst Dr. Steven Miles in his humorous "A Thai Dictionary of Medical Ethics" in which he described an example of the use of the term "futility"as "a siphon for removing puddles of water that form far ahead on highways on hot summer days." Medical futility is a bit more complicated than that. Recently, for me, a concise description of medical futility was made by an ethicist and teacher Laurence B. McCullough, Ph.D. on a bioethics listserv and with his permission, I present his words below. But also what I would like to read from my visitors is how they look at the term "futile" or "futility" in relation to its use by doctors and whether it represents to them as patients or family members of patients a term which has meaning and should be used. ..Maurice.
In its general clinical meaning, 'futile' means that in evidence-based reasoning there is no reasonable expectation that the usually intended outcomes of a clinical intervention will occur. The roots of the concept can be found in the admonition in the Hippocratic text, The Art, against the madness of thinking that clinical intervention has unlimited power to alter the course of disease or injury. (Blackhall in "Must we always use CPR?" suggested 100% failure rate or 97-99% failure rate with high and unacceptable morbidity.)
Providing futile clinical management is not consistent with professional integrity. (See Brett AS, McCullough LB. When patients request specific interventions: defining the limits of the physician's obligation. N Engl J Med 1986; 315: 1347-1351.) Professional integrity has been a consistent, core consideration of common law on end of life care, starting with Quinlan in 1976.
This general meaning of 'futility' must be specified, to be clinically applicable. (See Jones JW, McCullough LB. Postoperative futility: a clinical algorithm for setting limits. Br J Surg 2001; 88: 1153-1154; Rabeneck L, McCullough LB, Wray NP. Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Lancet 1997; 349: 496-498.)
Physiologic futility: no reasonable expectation that physiologic outcome will be achieved (e.g., antibiotics for viral infection, CPR on totally decapitated human being [from international resuscitation guidelines and my favorite], artificial administration of nutrition to a patient with cancer cachexia). Physiologic futility is not discredited by a transient physiologic effect, such an occasional heartbeat during CPR.
The first three specifications fall within clinical expertise; the fourth depends on clinical expertise (prognosis of functional status) but is also a function of the patient's values and beliefs.
Laurence B. McCullough, Ph.D.
Dalton Tomlin Chair in Medical Ethics and Health Policy
Center for Medical Ethics and Health Policy
Baylor College of Medicine